Request edit access
 Employee Report of Injury
Sign in to Google to save your progress. Learn more
Name *
Job Title *
Date and approximate time of incident/injury *
Where did this happen? Be specific (which building, room, hallway, gym, bathroom, parking lot, etc.) *
Description of incident. What happened? What were you doing at the time? *
Body part affected. Be specific (left or right hand, knee, arm, eye etc.) *
Names of any witnesses *
Was any medical treatment received at the time of injury, even if it was just basic first aid? If so, please describe the treatment. *
In your opinion, what, if anything, could have been done to prevent the incident? *
Did you report the incident to your supervisor or Human Resources? Date Reported?  *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Thomas Jefferson Classical Academy.

Does this form look suspicious? Report

Google Forms